ACCME Data Request Form 792_ Page 1 of 8

Transcription

1 The Accreditation Council for Continuing Medical Education (ACCME ) is committed to promoting a dynamic CME enterprise that is well-positioned to adapt to the changing educational needs and expectations of clinician-learners today and in the years to come. To realize our vision of leveraging education s power to improve the quality of care for the patients and communities we serve, the ACCME has identified Advocating for CME Scholarship as one of six goals in its strategic plan and has included it as a component of its Criteria for Accreditation with Commendation. The ACCME supports research that assesses the effectiveness of CME and/or identifies best practices in CME and/or is in service to the overall CME enterprise. The ACCME is, therefore, making available anonymized ACCME data (sample listed below) for appropriate research. Activity type and title Providership (direct or joint) Hours of instruction Designed to change competence, performance and/or patient outcomes Evaluated changes in competence, performance and/or patient outcomes Competencies addressed Number of physicians who participated in the activity Number of other learners who participated in the activity Commercial support received: total monetary amount and/or nature of in-kind commercial support received Advertising and exhibit income Registration fees Government grants Private donations MOC activities FDA Risk Evaluation and Mitigation Strategy activities AMA-PRA Category 1 Credits designated Researchers interested in utilizing anonymized ACCME data should complete and submit this form. Please note that incomplete submissions will not be considered. Comments and questions may be directed to research@accme.org. Page 1 of 8

2 Lead researcher Your current CV must accompany this data request form Contact information Mailing address Telephone Descriptive title of research project Organization name & department Institution associated with research project Mailing address Telephone Senior/key people associated with research project Name Organization/Title Page 2 of 8

3 Disclosure Please use the following ACCME definitions to identify and disclose all relevant financial relationships with any commercial interest. The ACCME defines "'relevant' financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests - unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria for promotional speakers bureau, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. Page 3 of 8

4 Research question(s) Data being requested Page 4 of 8

5 Methodology Goal of the proposed research Page 5 of 8

6 Benefit of the proposed research Project timeframe Page 6 of 8

7 Information security Study data must be maintained in a secure and controlled environment. Please check the information security practices to be used: Institute supported, controlled access server Institute supported, password protected desktop computer Encrypted, password protected laptop computer Encrypted portable media (encrypted external hard drive, encrypted thumb drive) Unencrypted portable media backup (CD, DVD, thumb drive) stored in locked file cabinet Private (institutional) or commercial encrypted cloud Funding source(s) Page 7 of 8

8 By submitting this Data Request Form, you: Recognize that, depending upon the nature and complexity of the request, a data processing and preparation fee may be incurred any fee will be determined during ACCME s review of the Data Request Form. Understand that all individuals who have access to the data being requested will be required to sign a non-disclosure/data protection agreement that may include additional terms beyond those in this Form. Agree that, upon completion of this project, you will (a) return or destroy the original data file and all copies, and derivatives whether combined or integrated into another data set; and (b) send the ACCME confirmation that this has been completed. Agree to submit progress reports to the ACCME, in keeping with an established/ agreed-upon schedule, that will include a summary of progress to date and a listing of anticipated publication submissions. Understand that the requested ACCME data may not be shared or transferred to any other researcher or any third-party, without the prior written permission of the ACCME. Agree to submit to the ACCME a pre-print or embargoed copy of any publication resulting from this project at least 21 days prior to the anticipated date of publication, and to provide the ACCME a copy of the published research after publication. ACCME will only respond to complete Data Request Forms that are accompanied by the following documents: Current CV of lead researcher Local Internal Review Board approval or exemption Applications are considered on an on-going basis in the order they are received. SUBMIT TO RESEARCH@ACCME.ORG Page 8 of 8